Small bowel, Tumor
=Introduction= There are a few questions to be addressed: #Is this tumor primary or metastatic? #What is the depth of invasion? #Are there metastases? #Are the margins free of tumor? #Is there any underlying mucosal pathology (IBD)? =Fresh Handling= #Measure: Length and diameter of specimen, staple lines, mesentery. #Ink proximal, distal, and deep margins (of tumor) of resection. #Open bowel; avoid cutting into tumor, if possible. Gently remove stool and or blood with saline rinse. #Photograph the opened specimen #Pin down on corkboard and fix overnight. Cut a few sections into the tumor and the mesenteric fat to allow better fixation. Consider tissue banking before fixing! =Grossing In= #Identify type of resection #Describe measurements as above. #Tumor characteristics: ##Size (including thickness), extent around bowel circumference, shape (fungating, flat, ulcerating), presence of necrosis or hemorrhage, extent through bowel wall, serosal involvement, satellite nodules, evidence of blood vessel invasion, invasion of adjacent organs. ##Distance of tumor to each margin of resection as applicable. #Other lesions in bowel and appearance of uninvolved mucosa; note presence or absence of associated polyps. #Estimate the number of lymph nodes found, and whether they appear to be involved by tumor, or not. Note size of largest node. #Summary of sections: ##Sections of tumor (3), including junction of carcinoma with normal mucosa on at least one, and full depth (with inked margin), including serosa on at least two sections. ##If specimen is obtained for a presumed adenoma, then take sections so that the relationship of the stalk to the bowel wall is maintained. ##Submit the entire head and stalk of the adenoma. ##Other lesions, if any. ##Margins of resection, proximal and distal. ##Lymph nodes (separate by contiguous to the tumor, proximal, and distal), remember you must get at least 10. Measure the enlarged lymph nodes and note if they seem involved by tumor. If so, a representative section is sufficient. Submit all other nodes entirely. =Sample Dictation= Specimen #___ is received fresh, labeled with the patient’s name and medical record number, designated "___“, and consists of a small bowel resection specimen measuring _ cm in length and _ cm in circumference, with a maximum wall thickness of _ cm. The mesenteric adipose tissue measures – cm. The specimen is received oriented. The distal end is designated with a suture and is closed by a ___ cm staple line; the proximal end is open. The external serosal surface of the specimen is grossly unremarkable, smooth and glistening, with no grossly apparent lesions. OR The external serosal surface of the specimen, inked entirely black, is indurated, retracted, with nodular lesions/ tumor implants, measuring _ cm, present in the proximal/distal bowel, _cm from the proximal/one stapled/closed/open end/margin and _ cm from the distal/second stapled/closed/open end/margin. The specimen is opened along its anti-mesenteric aspect to reveal a solitary, round/ovoid/irregular/exophytic/polypoid/ulcerating/infiltrative/diffuse, well/poorly circumscribed lesion, with irregular/rolled/raised/serpentine/puckered margins, measuring cm, _ in color, soft/firm/hard in consistency, with a homogenous/heterogenous, irregular/smooth, fleshy/variegated cut surface, with/without areas of hemorrhage and necrosis, { Solitary, firm, tan-red lesion, measuring – cm, with raised, heaped up serpentine borders and a central ulcerated bed }, located in the proximal/ distal bowel, _ cm from the proximal/one stapled/closed/open end/margin and _ cm from the distal/second stapled/closed/open end/margin. The lesion is situated _ cm from the nearest radial/circumferential margin and on serial sectioning (choose one): :Is predominantly an intra-mucosal lesion, not showing invasion into the submucosa, present _ cm from the nearest deep inked serosal surface. :Shows invasion into but not through the muscularis propria, present _ cm from the nearest deep inked serosal surface. :Shows invasion into and through the muscularis propria, but does not appear to be transmural, present _ cm from the nearest deep inked serosal surface. :Shows invasion into and through the muscularis propria, appears to be transmural, and grossly corresponds to the previously mentioned area of perforation, noted on the serosal surface, present at/ _ cm from the nearest deep inked serosal surface. The lesion occupies ___% of the circumference of bowel, with the minimal luminal diameter at the site of the lesion measuring _ cm, with/without proximal bowel dilatation (measuring – cm in maximum circumference), and with/without bowel perforation. The specimen on serial sectioning shows no other grossly apparent lesions. The adjacent uninvolved colonic mucosa is smooth, glistening and grossly unremarkable. The peri-colonic soft tissue is palpated and dissected for potential lymph nodes. Representative sections of the specimen are submitted as follows: Staple line/margin #1 as _ and _; staple line/margin #2 as _ and _; representative sections of the tumor (including inked serosal margin and transition to adjacent mucosa) as _ through _; additional mucosal lesions (polyps) as _; a representative section of unremarkable mucosa as _; appendix as _; potential lymph nodes as _ through _. =Review and Signout= The following should be included in the histologic description: *Degree of differentiation. *Depth of invasion, by layer. *Association (if any) with adenomatous precursor lesion. *Lymph node number and number of positive nodes. Separate if possible by group type. *Margins of resection. *Presence of vascular or lymphatic invasion. *Associated lesions, if any. Include staging in your comment or synoptic. Sample diagnostic lines #Small bowel, resection: :Adenocarcinoma, XX cm, (well, moderately, poorly) differentiated, invasive (into lamina propria without involvement of muscularis propria vs. into but not through muscular propria vs. through muscularis propria into the subserosal adipose tissue without serosal involvement vs. invasive through serosa), (with lymphovascular invasion vs. no lymphovascular invasion identified), see note. :Proximal and distal resection margins free of tumor. :X lymph nodes, no carcinoma identified (0/X) OR Metastatic adenocarcinoma in X of Y lymph nodes (X/Y). :Appendix with no specific pathologic change. Other possibilities: #Small bowel, resection: :(Well, moderately, poorly) differentiated neuroendocrine tumor, x cm, involving the submucosa (mucosa, muscularis propria, serosa) of the small bowel, see note. :Proximal and distal resection margins free of tumor. :X lymph nodes, no tumor seen (0/X). :(T/B) cell lymphoma involving small bowel, see microscopic description. :Lymphoma involving X of Y lymph nodes. :Margins of resection free of tumor Return to Gastrointestinal Grossing